American medical care has been placing this country under a tremendous financial strain and will continue to absorb an increasingly higher share of its resources into the indefinite future. Over the past 20 years its average cost increases, primarily of the institutional kind (hospitals, lab tests etc.), has risen annually at over twice the rate of inflation compared to the rest of the economy and will remain for the forseeable future as the most expensive sector of our consumer-driven society.
The reasons are chronic and multiple and in most cases simply reflect and stem from cultural features unique to 20th century American society. For example, an increasingly ageing population that will continue to consume a disproportionate share of our clinical resources, increased leisure time by all age groups that allows for such discretionary indulgences as more `health care` consumption that only creates more demand on a medical care system that is already oversubscribed to, the virtual doubling of american medical school graduates since the early 70's along with almost no effort to limit the entry of foreign medical graduates which in itself greatly expands the size of an already very elastic medical marketplace (i.e. the number of cars or refrigerators we buy is pretty fixed but not the number of times we might see a doctor). There is also the ever-present fear by doctors and hospitals of costly malpractice litigation that increases both front-end costs by higher insurance premiums and higher day-to-day costs by the defensive use of expensive tests and high-tech procedures done simply to lessen the risk of and protect against any future lawsuits.
In the wake of this dilemma in an open and free society several measures have been initiated separately and independently over time to curb costs and even improve quality of care. Unfortunately none have succeeded and the costs continue to skyrocket. That's primarily because none have addressed how we actually examine in a precise and large scale way how the daily practice of medicine is delivered and what the results actually are, especially on a comparative basis.
Up until now the `solutions` have only been regulatory and administrative in nature that in fact only interfere in the natural practice of every day medicine without a mechanism for actually assessing what has happened on a large-scale and precise analytical basis. And in many cases has only led to divisiveness and polarization amongst health care providers.
For example, the corporatization of American medicine by HMO's that use high-powered ad techniques and the `magic` of fixed pre-payments for subscribers as a way to control costs while never publicly acknowledging how their member doctors are gently co-erced to hold the line in the trenches by rationing through the limiting of tests and even office visits. But several HMO's, in Massachusetts for example, have already begun to experience financial problems and have been forced to merge due to an oversubcription by the elderly and the resultant encounter of greater than projected costs through vast and unanticipated increases in the use of resources. Also, despite the promise of cost reduction through so-called health care competition, the appearance of `alternate health care providers` like nurse practitioners and physicians assistants has been a failure in controlling costs primarily because it too only increases the size of the medical marketplace while also causing confusion over who does what, turf battles and duplication of effort. It has also caused a massive over-concentration of health care providers since these paraprofessionals always seem to locate in areas that are already heavily populated by doctors. As another example of the failure to control the cost of something as unpredictable and complicated as medicine, and therefore its consumption, is the lack of measurable success with DRG's or Diagnostic Related Groups. Basically, they are a method for assigning costs and fees to certain disease categories that's used by hospitals and insurance companies for pre-determining how much they should spend during a hospitalization. As such, they only address one aspect of medical care; hospitalization, are unable to examine on a large and precise basis the individual practices of doctors on a comparative basis and they create artificial boundaries that are overly and too neatly drawn between medical conditions that are often related and overlap clinically, and are naturally unable to take into account the many hidden uncertainties that frequently appear in clinical medicine and as such deal poorly if at all with unforseen complications. They have been operative for some time but they have failed to control costs while adding nothing to the quality of medical care.
None of the above measures have succeeded because they are superficial, politically expedient and often costly in themselves due to their promotion of additional regulations and new agencies that increase the administrative and bureacratic cost of medical care. Unfortunately none of them are designed to look directly at and examine what actually happens on a day-to-day basis at the level of the patient-physician encounter at that point in the medical care system that has traditionally been the most responsible for eventually determining how much we will spend; the primary care, general practice, out-patient setting. Until now, no one has bothered to look at what happens and why at the level of the primary care out-patient physician practice where all the medical-consumer habits, trends and diseases originate.
Primary care, out-patient medicine is the most frequent point of contact in the medical care system and until a method for its precise and large-scale analysis is found, a rational basis for cost control in medicine will never be obtained.
What is therefore needed is an automated method for looking at what doctors do, their observations, tests, treatments, and diagnoses, etc., on a daily basis to a large, organized and well defined population of out-patients in a primary care setting under clearly spelled out and uniform conditions and circumstances. A kind of primary care `audit trail system` that uses the power and flexibility of the computer to collect, store and process data under pre-defined conditions that enable applying uniform standards of analyzing care by doctors to patients in regard to both outcome and resource utilization.
My computer-based system, with its database and programs, is a model for demonstrating the feasibility of doing just that. It is an information-management-system for the analysis of clinical data processed by the computer in such a way as to reflect what has happened during the natural and traditional way out-patient medicine is conducted. It records the identical set of data under an identical method for all patients and then processes that data for specific groups of out-patients according to uniform criteria that create specific aspects of primary care medicine through the `customized` design of computer-program software.
Both out-patients and their doctors are members of the database. Each out-patient is placed into one of three diagnostic categories for the purpose of selective data processing that depends upon the single or combined value of up to three chronic diagnosis any one patient may have. Other elements of the system are a family of related files that store separate, related aspects and items of clinical medicine, many of which are linked to each out-patient as individual clinical attributes that contribute to the total medical profile of each out-patient. And as with other types of more common database systems, this one has two general types of files; transactional and inventory. The former are event-based, its records accumulating over time through data entry programs and how many of them any one patient has depends upon the condition or disease activity of that out-patient. On the other hand the inventory type files contain a fixed number of records and consist of data items that are used to affix those clinical attributes appropriate to any out-patient, i.e. symptoms, diagnosis, medicines, etc. that can clinically define them at any point in time.
Such a database, with its integrated set of related files of both types, then serves as the informational base for the processing operations conducted by a separate set of computer programs (other than the data entry ones) that are designed to simulate or mimic aspects or conditions of out-patient medicine. With such distinct and `logical views` that create special facets of out-patient clinical medicine drawn by such programs that now process that centralized pool of integrated clinical data stored in separate files, it becomes possible to apply precise and large-scale analysis uniformly from an outcome based perspective while also being able to look at what doctor did what and for what reason. Under uniform and standardized conditions you can now analyze clinical results about any number of out-patients from both the same diagnostic group or make comparative results between different diagnostic groups. And you can establish a level of priority in the analysis of results and resource usage that includes a measure of expectation by the selective processing of different diagnostic groups or out-patients within any group that differ by chronic diagnosis.
In short, my model database system collects and loads the same set of clinical data in the same way for out-patients classified according to diagnostic groupings. The data reflects the natural activity that normally occurs every day in a primary care setting. The data is then processed by an associated set of programs that select for certain clinical conditions and criteria that by design create special aspects of out-patient medicine. For example, viewing lab test results ordered during a special type of office visit in conjunction with other salient clinical data observed during that same visit that then enable determining if said lab tests ordered were justified in view of what that doctor observed about that out-patient. As another example, a computer program in this model system enables one to look at both symptoms and medications ordered during a special type of office visit for a group of patients with the same chronic diagnosis who are being cared for by the same doctor. In this way analysis is possible under conditions uniformly applied to groups of patients and doctors from highly focused aspects of out-patient, primary care medicine that make such analysis easy because it creates identical reference points for comparisons.
Such a model system, as outlined in this specification, can at least be used for one important purpose; to supplement the traditional `non-system` of medical record keeping. It can remedy the current system which, as everyone knows, is non-integrated and non-standardized, which is manually based and highly individualized from physician to physician depending upon that physician's personal bias or style. And as such is totally incapable of being viewed from specially created clinical circumstances through program design for special emphasis or on a large scale basis that can offer comparative analysis.
My model, computer-based system doesn't have to replace anything and it doesn't have to interfere with the way things have been done. But it offers, by way of proven technology, a new, different way of looking and analyzing the outcome and resource usage at the most frequent and critical point of our health care system from the long-term point of view: the primary care, out-patient setting.